AB 1223 (O'Donnell) Page 2 of 2
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1223
AUTHOR: / O'DonnellVERSION: / June 30, 2015
HEARING DATE: / July 8, 2015
CONSULTANT: / Vince Marchand
SUBJECT: Emergency medical services: ambulance transportation.
SUMMARY:
Requires the Emergency Medical Services Authority (EMSA) to adopt a statewide standard methodology for the calculation and reporting by a Local Emergency Medical Services Agency (LEMSA) of ambulance patient offload time, and permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time using the statewide methodology adopted by EMSA. Requires, if a LEMSA adopts a policy for calculating and reporting ambulance patient offload time, to establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time.”
Existing law:
1) Establishes EMSA, which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures.
2) Requires EMSA, utilizing regional and local information, to assess each EMS area or the system’s service area for the purpose of determining the need for additional emergency services, and the coordination and effectiveness of EMS.
3) Requires EMSA to develop planning and implementation guidelines for EMS systems which address specified components, including communications, system organization and management, and data collection and evaluation.
4) Authorizes counties to develop an EMS program and designate a LEMSA responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations.
5) Establishes an 18-member Commission on EMS, within the California Health and Human Services Agency (HHSA). Defines the duties of the Commission to include reviewing regulations, standards, and guidelines developed by EMSA; advising EMSA on a data collection system; advise on emergency facilities and services, emergency communications, medical equipment, personnel training, and various aspects of the EMS system; and, to make recommendations for further development of the EMS system.
This bill:
1) Requires EMSA to develop, and after approval by the Commission on EMS, adopt a statewide standard methodology for the calculation and reporting by a LEMSA of ambulance patient offload time, using input from stakeholders, including, but not limited to, hospitals, LEMSAs, and public and private EMS providers.
2) Defines “ambulance patient offload time” as the interval between the arrival of an ambulance patient at an emergency department, and the time that the patient is transferred to an emergency department gurney, bed, chair, or other acceptable location and the emergency departments assumes responsibility for care of the patient.
3) Permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time, and requires a LEMSA that adopts these policies and procedures to do all of the following:
a) Use the statewide standard methodology for calculating and reporting patient offload time developed by EMSA pursuant to this bill; and,
b) Establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time,” as defined in this bill.
4) Defines “nonstandard patient offload time” as an offload time that exceeds a period of time designated in the criteria established by the LEMSA, but excludes from this definition instances in which the offload times exceeds the designated period of time due to acts of God, natural disasters, or manmade disasters.
FISCAL EFFECT:
According to the Assembly Appropriations Committee, this bill will result in minor and absorbable costs to EMSA (General Fund or federal grant funds).
PRIOR VOTES:
Assembly Floor: / 76 - 0Assembly Appropriations Committee: / 15 - 0
Assembly Health Committee: / 19 - 0
COMMENTS:
1) Author’s statement. According to the author, when someone is picked up by an ambulance, they are taken to a hospital emergency department. Once the patient is in the ambulance the EMS crew becomes responsible for their care until they are signed over to hospital staff.
Patients who are suffering from a serious medical condition are quickly admitted into the hospital, but that is often not the case with patients with minor issues, who have to wait for a hospital bed to become available. A national study found that patient offload times had more than doubled since 2006, from 25 minutes to 45 minutes. Offload times in some parts of California can be much longer. EMSA reports that 13 of the states’ 33 LEMSAs identified the problem of ambulance patient offload times as an issue. These 13 agencies serve 70 percent of the state’s population. While some individual counties and hospitals have taken actions to alleviate the issue there has been no uniform, statewide, or comprehensive attempts to solve the problem of patient offload times or even define it. Without a common vocabulary when discussing this issue the state can’t begin to identify the problem let alone devise remedies.
2) Background and creation of toolkit to address offload delays. In 2013, the California Hospital Association and EMSA created the Ambulance Patient Offload Delay Collaborative to analyze and develop solutions for the offload delays that were increasing pressure on both hospitals and ambulance providers. The goals of this collaborative were to: 1) develop standardized language, definitions, metrics and reporting opportunities for ambulance patient throughput; 2) identify ways to reduce delays and improve transfer times; and, 3) assist local jurisdictions in developing processes and sustainable goals to reduce the incidence of ambulance patient offload delays. In a national study involving 200 cities, including some in California, the national average wait time for handing off ambulance patients has doubled from 20 minutes in 2006 to more than 45 minutes. Through survey research, the collaborative learned that the offload delay problem in California is not uniform or consistently reported. Of the 124 hospitals that responded to the survey, 74 (or 60%) said that offload delays were “neutral” or “not significant,” which was consistent with what 19 out of 33 LEMSAs (58%) reported as well. In contrast, 45 hospitals and 13 LEMSAs reported that offload delays were “extremely significant,” “very significant,” or “somewhat significant.” However, those 13 LEMSAs reporting a problem represent regions that include 70% of California’s population.
As a result of this collaborative effort, in August of 2014 the Toolkit to Reduce Ambulance Patient Offload Delays in the Emergency Department (Toolkit) was published by the California Hospital Association. The Toolkit includes definitions, process guidelines and strategies to be considered to evaluate current practices and develop specific process improvements at the local level. The theme of the Toolkit was that local EMS systems and hospitals are unique, and that collaborative problem solving should be used to identify and solve problems locally. However, the Toolkit did identify three key factors for success, starting with improving the emergency department intake process, followed by continuous quality improvement measures, and hospital and LEMSA collaboration.
3) Related legislation. AB 503 (Rodriguez), would permit a hospital to release patient-identifiable medical information to an emergency medical services provider, to a LEMSA, or to EMSA, for quality assessment and improvement purposes. AB 503 passed the Senate Health Committee by a vote of 8-0 on July 1, 2015.
AB 1129 (Burke), requires an emergency medical care provider, when submitting data to a LEMSA, to use an electronic health record system that is compatible with specified standards, and that includes those data elements that are required by the LEMSA. Prohibits a LEMSA from mandating that a provider use a specific electronic health record system. AB 1129 passed the Senate Health Committee by a vote of 8-0 on July 1, 2015.
4) Prior legislation. AB 1621 (Lowenthal, 2014), would have required EMSA to adopt a single statewide standard for the collection of information regarding pre-hospital care for CEMSIS, required EMSA to develop standards for electronic patient care records systems used by LEMSAs and local pre-hospital EMS providers to ensure compatibility with CEMSIS, and required LEMSAs to submit patient information to EMSA utilizing the single statewide standard in a timely manner. AB 1621 was held on the Senate Appropriations Committee suspense file.
AB 1975 (R. Hernández, 2014) would have required LEMSAs to contract with the American College of Surgeons every five years to conduct a comprehensive assessment of their regional trauma system. AB 1975 was held on the Assembly Appropriations Committee suspense file.
SB 535 (Nielsen, 2013), would have increased the membership of the EMS Commission from 18 to 20 members, and required the additional members to be an air ambulance representative appointed by the Senate Committee on Rules, and representative appointed by the Speaker of the Assembly from a public agency that provides air rescue and transport. SB 535 was vetoed by the Governor.
5) Support. According to the author, this bill is sponsored by the California Fire Chiefs Association (CFCA), which states in support that hospital emergency departments are more crowded and busier than ever, which means that EMS responders are spending more of their time waiting to offload patients at emergency departments than fulfilling their primary duty of responding to emergency calls. CFCA states that this bill seeks to help alleviate these issues by requiring EMSA to develop a methodology for determining an acceptable amount of time for EMS crews to offload their patients at emergency departments. The California Ambulance Association (CAA) states that it supports this bill because it believes that it will ultimately result in cost savings to the EMS system. According to CAA, patient offload time has been a significant problem for ambulance providers. CAA agrees that a crucial first step in dealing with this issue is to properly identify and define metrics to measure the issue. The California Professional Firefighters states in support that this bill represents a good first step toward the development of standards to expedite the transfer of care between ambulance personnel and the emergency department staff of a general acute care hospital and mitigate delays in returning ambulances and pre-hospital care personnel to the EMS system. Paramedics Plus states in support that a five minute wait time reduction in Alameda County equates to one 24 hour ambulance deployment per day back into the 911 EMS system.
6) Opposition. The California Hospital Association (CHA) states in opposition that numerous issues contribute to ambulance patient offload delays and emergency department crowding, and that hospitals are not the main problem. According to CHA, excess demand for emergency services, for the most part, is beyond both hospitals and EMS providers to exclusively solve. CHA states that standardization of ambulance patient offload delay methodology is a laudable goal, however, it does not address the individual local needs of each LEMSA and neighboring hospitals to solve problems with their existing resources. Finally, CHA states that the Ambulance Patient Offload Delay initiative has been operating for more than two years with many regional collaboratives already working collectively and cooperatively to solve this issue, and that legislation is unnecessary. According to CHA, one local area has discovered that offload delays are a product of their counties’ massive population growth with increased Medi-Cal patients seeking care in the area emergency departments, while another area showed that delays were attributable to the EMS crews restocking and completing their paperwork. CHA states that legislation that requires measurements that will be used in a retaliatory manner against hospitals is unfair and unnecessary.
SUPPORT AND OPPOSITION:
Support: California Fire Chiefs Association (sponsor)
California Ambulance Association
California Professional Firefighters
California State Firefighters’ Association
League of California Cities
Paramedics Plus
Oppose: California Hospital Association
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